National review calls for earlier and stronger pre‑birth safeguarding to protect vulnerable unborn babies and infants

The national review, published this month by the Child Safeguarding Practice Review Panel, called for earlier and stronger pre‑birth safeguarding, including national guidance that “explicitly includes vulnerable unborn babies and infants”, and “clearer protocols for responding to concealed or late‑disclosed pregnancies”.

Baby Victoria was born in December 2022 and died in early 2023 after her parents, Constance Marten and Mark Gordon, concealed her birth and deliberately evaded statutory services.

In 2025, both of baby Victoria’s parents were convicted of gross negligence manslaughter, child cruelty, perverting the course of justice, and concealing the birth of a child.

The Child Safeguarding Practice Review Panel noted: “While the circumstances of baby Victoria’s death are very rare, the review finds that the professional challenges and systemic safeguarding issues involved are much more common.

“The review highlights multiple risks in baby Victoria’s family circumstances including several concealed pregnancies, repeated child removals, domestic abuse, poor engagement with services, serious offending, and frequent moves between different areas.”

One chapter of the review explored the “complex issue” of concealed pregnancy - particularly among parents who have previously experienced the removal of children through care proceedings.

The panel highlighted the “legal and ethical tension” between a woman’s right to bodily autonomy and practitioners’ duty to safeguard unborn infants, and called for a “trauma-informed, preventative approach”.

The report noted: “Women do not have to seek or accept any midwifery or medical care during their pregnancy or childbirth. Unassisted birth is a matter of choice and not in itself a reason for raising safeguarding concerns with other agencies. This can limit the ability of safeguarding professionals who are concerned about an unborn infant to intervene unless a pregnancy is disclosed or detected.

“[…] Practitioners need to view concealment as a serious safeguarding concern and consider contextual information, particularly where previous removals have been made.”

The report called on government to “act urgently” to strengthen national guidance, improve information‑sharing between agencies, and ensure that professionals have the time, skills and support needed to safeguard unborn babies and infants effectively.

Other key findings and recommendations included:

• Trauma‑informed practice, to help reach families who do not engage with services, recognising that avoidance of services often reflects grief and mistrust rather than deliberate refusal;
• Better engagement with and support for parents before and after child removal, to help break cycles of harm and reduce repeat risk;
• A preventative ‘Think Family’ approach, bringing together adult and children’s services to provide a holistic view and identify issues that affect the whole family unit;
• Stronger links between children’s social care and offender management services, especially when serious sex offenders are parents or carers;
• Clearer arrangements when families move, including formal information transfer, shared chronologies and defined safeguarding responsibility.

Panel Chair, Sir David Holmes said: “Few tragedies are greater than the death of a baby, and baby Victoria’s is all the more devastating because her parents caused it.

“Baby Victoria lived in a family where there had been several concealed pregnancies, repeated child removals, domestic abuse, lack of engagement with services, serious offending and frequent moves. These are risks we see time and again in serious safeguarding incidents, and they are examined in depth in our review.

“While baby Victoria’s death was rare, her status as a vulnerable unborn baby and then a vulnerable infant is not. Last year, more than 5,000 unborn babies and infants under one were on child protection plans. Their parents are struggling, often disengaged from services, and many receive little support.”

He added: “A key lesson from baby Victoria’s story is clear: to protect vulnerable babies better, we must support their parents too. That may be hard to hear and hard to understand, but it is essential if we are to stop cycles of harm from repeating. Safeguarding professionals need the time, skills and resources to understand why families disengage and to address the underlying issues - whatever they may be - domestic abuse, substance use, mental health, trauma after previous child removals or anything else.

“That is why we are calling for improved national guidance for safeguarding vulnerable unborn babies and infants, and better support for parents whose children are removed. These changes will help reduce future harm.

“We cannot prevent every act of extreme parental harm - but we can reduce the risks in families and help people to move forward. That must be baby Victoria’s legacy.”

Responding to the panel’s findings, Education Secretary Bridget Phillipson said: “The Panel’s findings highlight complex issues – particularly around concealed pregnancy, persistent non-engagement with services, domestic abuse, risks associated with serious offenders who are parents, and the challenges that arise when families move frequently between areas.

“The Review also underscores the need for a proactive relational and trauma-informed, multi-agency safeguarding and child protection system, with clear pathways of support for parents and safeguarding of unborn babies. I welcome these insights which provide valuable learning for government and local statutory safeguarding partners and agencies.

“The government will now carefully consider the recommendations made. As part of this, we will be inviting the Panel to attend a future meeting of the Keeping Children Safe (KCS) Ministerial Board, so that ministers across government can collectively discuss the Review’s findings and reflect on the changes needed to strengthen systems nationally and locally.”

Lottie Winson